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FOR OFFICE USE:. — r Z (it -------------------:------------------------------------ i CA L --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No......................... -------------------------------------------------------- (Complete in Duplicate) 3 r 3- (.Q ----------------- Date This Permit Expires 1 Year From Date Issued Date Issued .._............. Application is hereby made to the San Joaquin Local Heal#h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. _- ---fOB ADDRESS AND LOCATION --------- 0 `,�1CC Owner's Name -----------��fL._Z,.'2— `------ 4�pFI- 5 Phone...Q40. Address-- ....................... ----- Z ----- Q ----------------------------------------------------------------------------------•------------------ �110-� =�-------------------------------------------------------- Phone --.-._..-_---- ---•-- Cantractor's Name----------------------• - ---------------------------------- --- Installation will serve: Residence iE�t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . � f Number of living units: ___1___ Number of bedrooms _2--_ Number of baths --- Lot size______-5_-.x__I_.__---------------------- Water Supply: Public system 4 Community system ❑ Private ❑ Depth to Water Table _ " ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ea Hardpan ❑ Previous Application Made: (If yes, date____________________) No New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ t No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - - f i ; Sgptic Tank: Distance from nearest well------------------ Distance from foundation ------- ------------ Material __________..________________________..__________. No. of compartments------------------------- Size -------------------------------- Liquid depth -------------------------- Capacity ----------------------- Disposal Field: Distance from nearest well-________________ Distance from foundation -------------------- Distance to nearest lot line______________... Number of lines ----------------------------------- Length of each line --------------------------- ._.Width of trench ------------------------------------ Type of filter material_________________________ Depth of filter material ----------------- ------ Total length ------------------------------- __________ Seepage Pit: Distance to nearest well ---- b�D-M __Distance from foundation___.-_ - �...... .Distance to nearest lot line __._._____.__ t,.® Number.of.pits--------------------- Lining material---- Gam--- Size: Diameter -----8---k .......... Depth ----- 2.!Y-___------------. . 14 Cesspool: Distance from nearest well------------------ Distance from foundation ---- -------___.___.Lining material ------------------------ _------------- ( , ❑ Size: Diameter. Depth -----------------•-----------------------. Liquid Capacity ----------------------------gals. v Privy: Distance from nearest well _________________f ------------------- ------------ Distance from nearest building ----------------------------------------- ❑ Distance to nearest lot line ------------------------------------- --------------------------------- --•-------------•----------------------------------------------------- Remodeling and/or repairing. (describe)= ----------- ---------- ------;-----------------------------------------------------------------•----------------------------------------------------------- --•----------------------------------------------- -------•--------------•---------•----------------------------------------------------- -- - - - ----------------------------------------------------•------------------------------- -- -------------------------------------------------------------------------------------------•-------------------------------- r I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and°r gulations of the San Joaquin Local Health District. {� I (Signed) t!' t - --- �I I _�C___ ____________ _ Owne and or Contractor B • (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------- -- - --- ---------`------------------- - ---- DATE-------- I = i - . --r - - '� -` REVIEWEDBY------------------------------------------------------------ - -----------------------------------------. DATE------ -! ----. ---- ------------------------------- BUILDINGPERMIT ISSUED ------------------------------------------- =------------------------------------------------ DATE ------ ------- ------------ --------- A ---------------------- Alterationsand/or recommendations---------------- ------ ------------ -----------------------•------------------------------------------------•----------•------------------------•-------------- ------------------------------Y ------------------------------------------------- ' -- ------------------------------------------------------------------------------------------------------------------------ --------- - -- -- --- ''-------------- ----------------------------------------------------- -----------------------------�---------------------------•-------- ---- - I FINAL INSPECTION BY:...:d`.JcT-------------------- ----- Date-.- ------------------------- �' { .-SANLOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi, California Manteca, CaliforniaTracy, California ES -9 RrvIBCD B-59 F.F.yp. ZM 6-64 #